Coronary Artery Calcium Scoring denials in California external review
In the California DMHC record, independent physician reviewers decided 15 published external-review cases involving Coronary Artery Calcium Scoringand overturned the plan’s denial in 13.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 10% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 20% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) of the heart without dye with quantitative evaluation of coronary calcium for evaluation of her medical condition. Findings: Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. There has been growing evidence on the use of coronary artery calcium (CAC) screening in better-studied cohorts of patients and asymptomatic individuals. CAC scoring has an increasingly high level of quality evidence on its role in risk stratification of asymptomatic patients. The accumulating evidence suggests that asymptomatic individuals with an intermediate Framingham risk score (FRS) may be reasonable candidates for coronary heart disease testing using CAC as a potential means of modifying risk prediction and altering therapy.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiac calcium score computerized tomography (CT) scan. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on the prevention of cardiovascular disease note that coronary artery calcium scoring (CACS) may valuable, actionable information. This is particularly if the CACS is zero, which would obviate the need for lifelong statin therapy or treatment with a proprotein convertase subtilisin/kexin type 9 serine protease (PCSK9) inhibitor. Conversely, an elevated CACS may reclassify the patient’s cardiovascular risk upward and justify the benefit of lifelong statin therapy, or possibly a PCSK9 inhibitor in the case of this patient, who is statin intolerant.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for computed tomography (CT) of the heart, without contrast, with quantitative evaluation of coronary calcium. The American College of Cardiology (ACC) and American Heart Association (AHA) guideline on the management of blood cholesterol supports the use of coronary artery calcium (CAC) scoring in the decision to withhold, postpone, or initiate statin therapy in non-diabetic intermediate and select borderline risk patients who lack atherosclerotic cardiovascular disease (ASCVD) risk-enhancing factors. Statin therapy is known to promote calcification of soft atheromatous plaque, thus leading to more stable, lower-risk compositions. This is often associated with an acceleration of the Agatston CAC score. As such, the prognostic utility of CAC for statin-treated patients is not well characterized.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage computed tomography (CT) scan to measure calcium in the coronary arteries. Primary prevention of arteriosclerotic cardiovascular disease requires attention to prevention and management of arteriosclerotic cardiovascular disease risk factors. Elevated serum cholesterol, usually defined by low-density lipoprotein (LDL) cholesterol, is a major arteriosclerotic cardiovascular disease risk factor. A patient’s 10-year arteriosclerotic cardiovascular disease risk should guide therapeutic considerations in patients ages 40 to 75. The higher the estimated arteriosclerotic cardiovascular disease risk, the more likely the patient will benefit from evidence-based statin treatment.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Coronary Artery Calcium Scoring, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY